What is the management approach for a patient experiencing a bolus sensation?

Management of Bolus Sensation

The management of bolus sensation should begin with ruling out organic causes through appropriate diagnostic testing, including endoscopy, followed by treatment of any underlying conditions such as gastroesophageal reflux disease (GERD) or esophageal motility disorders with proton pump inhibitors and/or prokinetics. 1, 2

Initial Evaluation

• Immediate medical attention required if patient presents with:

  • Difficulty breathing or stridor
  • Inability to swallow saliva
  • Progressive symptoms
  • Fever
  • Taking anticoagulant medications 1

• Diagnostic imaging:

  • Plain radiographs have limited utility (up to 85% false-negative rate)
  • CT scan is highly recommended for accurate assessment of foreign body location and complications
  • CT scan with oral contrast if perforation is suspected 1

Diagnostic Workup

1. Endoscopic evaluation:

   • Recommended for suspected esophageal disorders
   • At least 6 esophageal biopsies from different anatomical sites should be obtained to confirm conditions like eosinophilic esophagitis (EoE) 1
   • Flexible endoscopy has a success rate of up to 90% for foreign body removal 1

2. Esophageal motility testing:

   • Should be performed if patient is non-responsive to initial PPI therapy
   • Nearly 48% of PPI-resistant patients with globus sensation have abnormal esophageal motility, with ineffective esophageal motility being most common 2

Treatment Algorithm

First-line Treatment:

1. For suspected GERD-related bolus sensation:

   • High-dose proton pump inhibitor (PPI) therapy 2
   • Continue for at least 4 weeks to evaluate response

2. For actual food bolus impaction:

   • Endoscopic intervention is first-line treatment, especially in EoE patients 1
   • Combined flexible and rigid endoscopy may enhance visualization and retrieval 1

Second-line Treatment (for PPI non-responders):

1. If abnormal esophageal motility detected:

   • Add prokinetics to PPI therapy 2
   • Consider esophageal dilation for strictures or rings 1

2. If normal esophageal motility:

   • Consider cognitive-behavioral therapy
   • Anti-depressants
   • Gabapentin may be helpful 2

For Acute Management of Food Bolus:

• Pharmacological options (if endoscopy not immediately available):

  • Glucagon
  • Nitrates
  • Calcium channel blockers
  • Benzodiazepines 3
  • Note: These should be used with caution and only in selected patients

• Non-medicinal approaches:

  • Drinking water or other fluids to help wash away small food particles 1
  • Effervescent agents (limited evidence) 3
  • Papain use is obsolete and not recommended 3

Post-Treatment Care

• Close monitoring for at least 2 hours after intervention
• Suspect perforation if patient develops pain, breathlessness, fever, or tachycardia
• Provide clear written instructions on fluids, diet, and medications
• Withhold PPIs for at least 3 weeks prior to follow-up endoscopy if EoE is suspected but not confirmed 1

Prevention

• Advise patients to chew food properly and eat slowly
• Identify and treat underlying esophageal disorders (found in up to 25% of patients with food bolus impaction)
• For confirmed EoE, consider topical corticosteroids and dietary therapy to reduce risk of recurrent food bolus obstruction 1

Important Considerations

• Stasis of both liquid and solid boluses occurs frequently even in healthy individuals and can be physiological 4
• The relationship between esophageal motility and transit is complex; manometry alone cannot perfectly predict bolus transit 4
• Always consider underlying pathology such as EoE, esophageal stricture, hiatus hernia, esophageal web or Schatzki ring, achalasia, and tumors 1